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A mother and 11 babies died unnecessarily at Furness General Hospital, a report has concluded. The report is the culmination of an 18-month investigation that the Government commissioned following years of concern by parents about neonatal and maternity care at the hospital.

The report is damning. It lists 20 major failings at the hospital dating back to 2004. Despite a series of serious untoward incidents, including five in 2008 alone, it was not until 2011 that the standard of care at the hospital attracted public attention.

In the meantime, numerous opportunities to investigate concerns were missed or deliberately avoided. The trust itself ordered an independent investigation that reported in March 2010, highlighting serious concerns about maternity care. The trust suppressed that report.

In June 2010, the Care Quality Commission (CQC) made an unannounced inspection of the hospital but concluded that it had no concerns.

Those findings contributed to the success of the trust's application later in 2010 for coveted "Foundation" status. Although its application included disclosure of the serious untoward incidents, Monitor, the body responsible for the decision, raised no concerns.

It was only in 2011 following the inquest into the death of baby Joshua Titcombe that public attention was drawn to the hospital's failings. Joshua had died of sepsis nine days after his birth in November 2008. His parents had repeatedly asked midwives at the hospital if Joshua needed antibiotics but they said that Joshua would be fine. The coroner found that midwives had repeatedly missed opportunities to diagnose and treat Joshua's infection. He also found that key medical records had gone missing without trace and that midwives had colluded to cover up their mistakes.

Today's report concludes that there was a "disturbing" catalogue of missed opportunities, not only at the hospital but also by the whole regulatory system which failed to investigate clear causes for concern. It highlights that the Department of Health relied on "misleadingly optimistic" regulatory assessments and that the local health authority and the Health Ombudsman should have recognised and taken steps to raise concern earlier.

At least six midwives are under investigation and due to appear before the Nursing and Midwifery Council (NMC) later this year. Police investigations into the death of Joshua Titcombe are on-going.

Commenting on the report, Andrew Clayton of Penningtons Manches' clinical negligence team, explains: "This hospital had a maternity unit that was dysfunctional according to today's report. Yet the trust, local health authority and health regulators all failed to act both on patients' concerns and on their own and independent reports that clearly identified serious concerns. The fact that some of the failings at Furness General came after the condemnation of care at Mid-Staffordshire Hospital is alarming. Of even graver concern is the fact that multiple different bodies charged with regulating and investigating healthcare failed to heed and to act on clear warning signs.

"It is only because of the sheer tenacity of those affected including, in particular, Joshua's father, James Titcombe, that attention was ever drawn to the substandard maternity care at this hospital. Twelve unnecessary deaths is not only unacceptable but incomprehensible. This report highlights widespread failings of the multiple regulatory bodies, all of which fundamentally failed to deliver safeguards to protect patient safety. Urgent action is needed to address the recommendations made in today's report to restore public confidence in a system that had clearly failed patients and their families."

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